CORE PLAN/HSA
Medical benefits are provided through Anthem Blue Cross Blue Shield. Consider the physician networks, premiums, and out-of-pocket costs for each plan when making a selection.
Plan Details
Network
BCBS
Plan Type
-
HSA Eligible
Yes
FSA Eligible
-
Carrier
Anthem Blue Cross Blue Shield
CORE PLAN/HSA Premiums
WEEKLY CONTRIBUTIONS
| Coverage Tier | WELLNESS | NON-WELLNESS |
|---|---|---|
| Employee only | $15.35 | $31.51 |
| Employee + spouse | $69.14 | $101.45 |
| Employee + child(ren) | $65.24 | $81.40 |
| Employee + family | $123.55 | $155.86 |
Employee only
- WELLNESS
- $15.35
- NON-WELLNESS
- $31.51
Employee + spouse
- WELLNESS
- $69.14
- NON-WELLNESS
- $101.45
Employee + child(ren)
- WELLNESS
- $65.24
- NON-WELLNESS
- $81.40
Employee + family
- WELLNESS
- $123.55
- NON-WELLNESS
- $155.86
Medical Services
| Service | IN-NETWORK |
|---|---|
| Annual deductible - individual | $3,400 |
| Annual deductible - family | $6,800 |
| Coinsurance (employee pays) | 10%* |
| Annual out-of-pocket maximum (maximum includes deductible) - individual | $5,000 |
| Annual out-of-pocket maximum (maximum includes deductible) - family | $10,000 |
| Preventive care | Covered 100% |
| Primary care | 10% coinsurance* |
| Specialist services | 10% coinsurance* |
| Mental health -: inpatient | 10% coinsurance* |
| Mental health -: outpatient | 10% coinsurance* |
| Urgent care | 10% coinsurance* |
| Emergency room | 10% coinsurance* |
Annual deductible - individual
- IN-NETWORK
- $3,400
Annual deductible - family
- IN-NETWORK
- $6,800
Coinsurance (employee pays)
- IN-NETWORK
- 10%*
Annual out-of-pocket maximum (maximum includes deductible) - individual
- IN-NETWORK
- $5,000
Annual out-of-pocket maximum (maximum includes deductible) - family
- IN-NETWORK
- $10,000
Preventive care
- IN-NETWORK
- Covered 100%
Primary care
- IN-NETWORK
- 10% coinsurance*
Specialist services
- IN-NETWORK
- 10% coinsurance*
Mental health -: inpatient
- IN-NETWORK
- 10% coinsurance*
Mental health -: outpatient
- IN-NETWORK
- 10% coinsurance*
Urgent care
- IN-NETWORK
- 10% coinsurance*
Emergency room
- IN-NETWORK
- 10% coinsurance*
- *After deductible
RETAIL RX (30-DAY SUPPLY)
| IN-NETWORK | |
|---|---|
| Generic | 10% coinsurance* |
| Preferred | 10% coinsurance* |
| Non-preferred | 10% coinsurance* |
Generic
- IN-NETWORK
- 10% coinsurance*
Preferred
- IN-NETWORK
- 10% coinsurance*
Non-preferred
- IN-NETWORK
- 10% coinsurance*
- *After deductible
MAIL ORDER RX (90-DAY SUPPLY)
| IN-NETWORK | |
|---|---|
| Generic | 10% coinsurance* |
| Preferred | 10% coinsurance* |
| Non-preferred | 10% coinsurance* |
Generic
- IN-NETWORK
- 10% coinsurance*
Preferred
- IN-NETWORK
- 10% coinsurance*
Non-preferred
- IN-NETWORK
- 10% coinsurance*
- *After deductible
Plan Notes
- If you have several covered dependents, all charges used to apply toward a “per individual” deductible amount will also be applied toward the “per family” deductible amount.
- When the family deductible amount is reached, no further individual deductibles will have to be met for the remainder of that plan year.
- No member may contribute more than the individual deductible amount to the “per family” deductible amount.